H Muscle Flap Transposition for Treatment of Diabetic Wounds of the Lower Extremity Keleigh Muxlow DPM1, Dresden Beier DPM1, Edgardo R. Rodriguez-Collazo DPM2, Tudor Tien MD1 1 Henry Ford Allegiance and Ankle Fellowship, Henry Ford Allegiance, Jackson, MI 2 Presence St. Joseph Hospital, Chicago, IL

Purpose: Figures 2a, 2b, 2c Hemisoleus muscle flap, Full incorporation of Abductor Hallucis Flap: 52 yo diabetic male with chronic ulceration right heel. He underwent multiple attempts of Treatment of diabetic ulcerations of the lower extremity is technically challenging. Factors muscle flap, Ulceration on contralateral limb wound debridement with allograft and application of wound vac. Due to the plantar medial such as neuropathy, excess biomechanical pressure, limited soft tissue availability, and location of the wound, an abudctor hallucis flap was planned. A ventral incision was made vascular compromise make wound healing difficult. Exposed bone, joint, and/or , tendon are along the medial aspect of the foot to the 1st metatarsal. The plantar fasica was incisied from also difficult to treat while avoiding infection. Muscular flap transposition is a powerful the medial and lateral border of the abductor hallucis. The insertion of the abductor hallucis treatment option which not only provides soft tissue coverage, but also increased vascularity was identified at the calcaneal tubercle. The muscle belly was dissected off of the base of the from the overlying muscle belly. This case study presents our experience with three patients proximal phalanx and the proximal was ligated. The flap was then rotated proximally who underwent local muscle flap transposition, two extrinsic and one intrinsic muscle flap, and inset into the defect. The flap was then covered with xenograft and wound vac negative for treatment of diabetic ulceration. Although current literature describes favorable results pressure therapy. A split thickness skin graft was placed three weeks later. The patient with local muscle flap transposition, underutilization of this treatment may be due to lack of remained non-weightbearing for eight weeks until the patient had full incorporation of the familiarity with this option by many community based providers. Multiple authors report graft. Three months later, the patient had recurrence of the ulceration from diabetic shoes. success of flaps in high volume settings.1,5,6,7,8 To our knowledge, there are no case reports He was placed in a total contact cast, which caused him to ulcerate on the medial malleolus. in the literature of muscle flap transposition for treatment of diabetic wounds performed in a Patient is currently non-weight bearing and undergoing local wound care. local community based hospital. Figures 4a- 4d: Clinical photo, Abductor Muscle Flap, STSG, Reverse Hemisoleus Flap: A 72 yo diabetic female presented to an outside ER with a displaced ankle fracture that was Flap: Incorporation of flap, Medial malleolar ulceration 68 yo diabetic female with history of below knee amputation presents with chronic ulceration closed reduced and casted. Three weeks later she presented with nausea, fever, chills. Upon of lateral malleolus of the contralateral limb. She underwent multiple wound debridements removal of the cast she had an ulceration of the medial malleolus with exposed bone and was and application of xenograft. The patient had osteomyelitis of her distal fibula. A limb admitted to our hospital. She underwent initial debridement of the ulcer with complete salvage attempt was made utilizing the peroneus brevis muscle flap. resection of exposed tibialis anterior tendon and placed in a delta frame. Due to the medial The distal fibula was resected and the ankle joint was prepped for fusion. Next, an intra- location of the ulceration and exposed bone, a hemisoleus muscle flap was planned. Vascular operative doppler was used to identity the distal perforating artery at approximately 4-5 cm studies revealed that she had perforators of the posterior tibial artery supplying the soleus proximal to the lateral malleolus and marked. A longitudinal incision was made overlying the muscle belly. The ankle joint was prepped for a fusion due to the loss of the powerful lateral compartment from the head of the fibula to 3 cm proximal of the distal fibula. The dorsiflexor, tibialis anterior. Next, a longitudinal incision was made 2 cm medial to the medial peroneal muscle bellies and the superficial peroneal were identified. Next, the border of the tibia. The medial half of the belly was carefully dissected from peroneus brevis muscle belly was detached from the proximal fibula. The muscle belly was the medial gastrocnemius and FDL. At the junction of the proximal and middle third of the transposed distally leaving three fingerbreadths from the distal aspect of the fibula. The soleus muscle, the medial half was divided and split longitudinally along the raphe after the patency of the distal perforator was assessed. The muscle belly was then inset into the defect distal perforators were identified. The muscle belly was rotated 180 degrees and inset over with 4-0 monocryl. The flap was then covered with xenograft and wound vac. A circular, the defect. Flap viability was assessed by both clinical appearance and intra-operative doppler external fixator was placed for compression across the fusion site and offloading of the graft of the distal pedicle. The flap was then covered with xenograft and wound vac. A circular side. Split thickness graft was placed two weeks after. This patient did have distal flap external fixator was placed for compression across the fusion site and offloading the area of necrosis, and underwent debridement, further split thickness skin grafting, a transpositional the graft. This patient did experience distal tip necrosis of the flap, however with further skin plasty. She was in non-weight bearing in the external fixator for twelve weeks and debridement and split thickness skin grafting went on to full incorporation. She remained non- transitioned to diabetic shoes upon incorporation of the flap. Despite full incorporation of the weightbearing for a total of eight weeks and transitioned into a total contact cast and Discussion: flap, the ulceration did recur distal to the transfer and is currently undergoing local wound This case study details our experience with muscle flap transposition for the treatment of eventually a CROW. Patient did have secondary ulceration of the plantar heel of the care. diabetic wounds of the lower extremity in a community hospital. Our surgical principles and ipsilateral limb and contralateral plantar foot two months later due to charcot rocker-bottom techniques are presented. Although, all patients had survival of the transposed flap, the deformity. Currently the patient is undergoing off-loading and local wound care. Figures 3a- 3d: Clinical photo, PB Muscle Flap, STSG, Incorporation of extrinsic flaps were complicated by distal flap necrosis. Due to the multiple comorbidities of this patient population, pre-operative studies are vital for flap survival. Determination of Figures 1a and 1b: Clinical photo, CT angiogram flap peripheral arterial disease with appropriate vascular consultation and imaging studies is important in pre-operative planning to assess regional vascularity of potential muscle flaps. 3,4 As described in current literature, distal tip necrosis is a common complication.1,4,5,7 Authors recommend careful, precise flap dissection and avoiding tourniquet use during these procedures to allow assessment of flap viability. Because superficial skin shear can occur, external fixators are recommended for stability and protection at the transfer site.3 In conclusion, muscle flap transposition is a very useful tool for limb salvage in diabetic patients with chronic, non-healing ulcerations. As these patients have complex medical conditions and comorbidities which defy easy solutions, frequent follow-up and preparation for management of ongoing problems is imperative. References: 1) Attinger, Christopher E., Ivica Ducic, Paul Cooper, and Charles M. Zelen. "The Role of Intrinsic Muscle Flaps of the Foot for Bone Coverage in Foot and Ankle Defects in Diabetic and Nondiabetic Patients." Plastic and Reconstructive Surgery 110.4 (2002): 1047-054. Web. 2) Bach, Alexander D., Mareike Leffler, Ulrich Kneser, J??rgen Kopp, and Raymund E. Horch. "The Versatility of the Distally Based Peroneus Brevis Muscle Flap in Reconstructive Surgery of the Foot and Lower Leg." Annals of Plastic Surgery 58.4 (2007): 397-404. Web. 3) Collazo, Edgardo R. Rodriguez, Christopher Bibbo, R. Jordan Mechell, and Adam Arendt. "The Reverse Peroneus Brevis Muscle Flap for Ankle Wound Coverage." The Journal of Foot and Ankle Surgery 52.4 (2013): 543-46. Web. 4) Collazo, Edgardo R. Rodriguez, Grady, John F. , Hernandez, Telva E., Nagesh, Darshan. “An Introduction to Lower Limb Muscle Flaps and Reconstruction: A Cadaveric Atlas”. 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"Improving Outcomes of the Distally Based Hemisoleus Flap: Principles of Angiosomes in Flap Design." Plastic and Reconstructive Surgery 123.6 (2009): 1748-754. Web. 10) Schwabegger, Anton H., Maziar Shafighi, and Ralfi Gurunluoglu. "Versatility of the Abductor Hallucis Muscle as a Conjoined or Distally-Based Flap." The Journal of Trauma: Injury, Infection, and Critical Care 59.4 (2005): 1007-011. Web. 11) Schwabegger, Anton H., Maziar Shafighi, Christoph Harpf, Alex Gardetto, and Raffi Gurunluoglu. "Distally Based Abductor Hallucis Muscle Flap: Anatomic Basis and Clinical Application." Annals of Plastic Surgery 51.5 (2003): 505-08.

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